Seclusion & restraint: a historical perspective

(1) The use of restraints in the care of psychiatric patients has been a topic of ethical controversy since the beginning of psychiatric medicine. (2) Enlightenment physicians regarded psychiatric illness as the loss of reason, and many advocated the use of restraints to help violent patients regain the use of reason. (3) John Conolly, a British alienist (a term used for psychiatrists) of the mid 1800s, claimed it was possible to treat psychiatric patients without the use of mechanical restraints, but he made liberal use of seclusion and physical restraint by attendants to manage violent behavior. (4) American alienists expressed misgivings about the use of mechanical and chemical restraint but most were reluctant to relinquish any usable intervention.     

Seclusion. The nursing challenge.

The research to date shows that there is not much data to guide nursing decisions about the use of seclusion. The justification for its use is not always as clear as one might hope. Although many patients are secluded for violence against themselves or others, there are others who have not been violent who are secluded. There may be justification for secluding violent patients, but, as indicated earlier, it may reinforce the behavior it is designed to stop. There probably is no justification for secluding patients who make loud noises, refuse to take medication, or refuse to participate in activities. In addition, it is disconcerting that a large percentage of patients are secluded for "escalating agitation," that is, they have not acted violently against themselves or others. What is problematic is that staff are undoubtedly predicting violent behaviors in these patients--predictions that might be erroneous. Thus, there is ample room for injustice to occur. The potential for injustice is even greater if certain patients are singled out for seclusion or if patients are secluded longer than they or the staff think that they need to be, as is indicated in some of the studies to date. Moreover, if unit variables are associated with seclusion activity, this too, may be indicative of decision making at certain times of the day or by certain staff members that may not be in the best interest of the patient. What seems fairly clear is that secluding a patient is a distressing event for staff and is viewed extremely negatively by some patients and as a reward by others.(ABSTRACT TRUNCATED AT 250 WORDS)     

Nursing staff's attitudes toward seclusion & restraint

1. Staff preferred to treat patients as they themselves wanted to be treated. 2. More than one third of respondents did not view seclusion and restraint use as a time for a therapeutic intervention. 3. If staff are practicing from their belief patterns, they will choose interventions to avoid use of seclusion and restraint. 4. The majority of respondents preferred using medication to treat out-of-control behavior because they considered it less restrictive.     

Staff resistance to restraint reduction: identifying & overcoming barriers

Professional organizations, regulating agencies, and hospital administrators have taken a strong stance on restraint reduction policies. When implementing a restraint reduction initiative, it is important to identify the barriers to restraint reduction, such as concern for personal safety, lack of knowledge about and practice using alternate de-escalation skills, and fear of disrupting the therapeutic milieu by using a variety of de-escalation methods. Education aimed to reduce the use of restraints needs to do more than simply provide information. It is important to acknowledge the emotional response of the nursing staff and the culture of the current practice. A variety of educational strategies, including role-playing, and case studies will help identify attitudes, beliefs, and behaviors that are congruent with reducing the use of restraints. If the ultimate goal of restraint reduction is philosophical change, it will eventually lead to a new culture of practice.     

Understanding the placebo effect. Part 2: underlying psychological & neurobiological processes

Placebo and nocebo effects are interesting and complex phenomena. In this article, I discuss some findings about the psychological and neurobiological processes that may underlie these effects on the basis of studies of pain, Parkinson's disease, and depression. From a psychological perspective, expectancy and conditioning theories have been used to explain placebo and nocebo effects. These psychological processes may be translated into physiological effects through overlapping brain circuits that are important for cognitive information processing, analgesia, and reward expectations. These brain circuits may represent a fundamentally important common underlying pathway that mediates placebo and nocebo effects in many conditions. Understanding these effects is important for designing clinical treatment studies and interpreting their results and is highly relevant for clinical practices.     

Sensory approaches in inpatient psychiatric settings: innovative alternatives to seclusion & restraint

The national initiative to decrease the use of seclusion and restraint in psychiatric inpatient settings requires innovative methods to facilitate the processes of consumer self-organization, self-care, and positive change. Sensory-based approaches and multisensory rooms are valuable resources as cultures of care shift to become more responsive and collaborative. This article explores the importance and efficacy of trauma-informed approaches that are sensory supportive, address the individual needs of the person, and strengthen the therapeutic relationship.     

Remarriage after divorce: recent changes and demographic variations

Using data from US Bureau of the Census publications from the decennial censuses and the Bureau's Current Population Reports, the authors analyze remarriage in the US. Among adults who had ended their 1st marriage in divorce, about 3/4 of the elderly men and 2/3 of the elderly women in both 1970 and 1980 were found to be remarried. However, the general decline in remarriage at the younger ages during the 1970s was accentuated among those under 35 years old. Although the proportion remarried among women with graduate school training was the smallest, that proportion declined less during the 1970s than for women in any other educational level. In both 1970 and 1980, the proportion remarried was positively correlated with personal income for men but negatively for women. An estimated 2/3 of those who end their 1st marriage in divorce will eventually remarry while they have young children living with them. During the lifetime of women in their 2nd marriage after their 1st marriage ended in divorce, only 1/3 of their children are born after remarriage, whereas 2/3 are born before their 2nd marriages. During the 1970s, the proportion of currently divorced adults living alone or sharing the homes of relatives diminished, while the proportion living as cohabitants outside marriage rose substantially. It appears as if both the divorce rate and the remarriage rate are approaching a period of relative stability.     

An economic evaluation of recent changes in Singapore's family planning program

Recently the Singapore government has stopped promoting family planning as a general policy applicable to all sections of society. A more selective policy has emerged, in which some groups are still urged to adopt family planning, while others are encouraged to have larger families. Using project evaluation techniques, part of the rationale behind this change is explored in this paper. The question of whether a general family planning program is no longer viable in view of recent developments in the Singapore economy is considered. The results support the movement away from a general policy on the assumption that the economy will continue to grow at the average rate observed since the early 1970s. However, a general policy would still be viable if the negative real growth of 1985/6 were to continue.     

The publishing of recent economics Ph.D. recipients

We present publication data for recent graduates of 50 economics Ph.D. programs. The data show that publishing output is highly concentrated among graduates of the top programs; the top three programs, for example, generate more than 25% of aggregate publishing output in our sample. We use the data to construct a set of program rankings based on both per capita and aggregate graduate publication and a comparison of faculty performance to graduate performance. The graduate/faculty comparison reveals that programs may be identical in the output of their faculties but starkly different in the output of their graduates.     

Street trees in Paris are sensitive to spring and autumn precipitation and recent climate changes

Urban Ecosystems - Determining the main factors causing urban tree decline is becoming essential for sustaining their health and survival. Understanding responses of tree growth to urban...     

Traumatic war. Stress & schizophrenia.

1. An examination of the effects of the Lebanese war on the citizens found that traumatic war events can be regarded as of primary importance for risk factors triggering the onset of schizophrenia. 2. The overall findings indicate an increase in the rate of admission for men diagnosed with schizophrenia throughout the 12 years of the war. The most significant increases occurred either following intensive fighting episodes or months later due to the additive effect of stress. 3. How soon individuals are affected by environmentally induced war stress may be related to their level of vulnerability to the disorder.     

Wearing two hats. Consumer & provider.

To change public attitudes toward people with mental illness, consumers need positive visibility and a strong community voice. We are making progress, although slowly, to eliminate the stigma surrounding mental illness. Progress can be attributed to the fact that the mentally ill are now living in our communities among us, and people are beginning to understand them more.